Indiana LTC Case Mix Auditsprovider.indianamedicaid.com/media/81399/sdg final 09_2012 ver 5.pdf ·...

©2010 Hewlett-Packard Development Company, L.P. The information contained herein is subject to change without notice 1

HP Enterprise Services

September 2012

Indiana LTC Case Mix Audits

2 HP Enterprise Services, September 2012

HP LTC Audit Team

Kimberly Honeycutt, RN, QMRP, RAC-CT LTC Manager

Vikki Dossett RN

Mary Elsbury LSW, QMRP

Anne Rosengarten LSW, QMRP-D

Joy Thompson RN, RAC-CT

Beth Steele RN

3 HP Enterprise Services, September 2012 3

What’s New: Indiana Health Coverage Programs (IHCP)Website-LTC Pages

For Up to Date Information:

http://www.indianamedicaid.com


What’s New: Indiana Health Coverage Programs (IHCP)Website-LTC Pages

– IHCP Bulletins/Banner Pages/Newsletters

– Future Virtual Training Offerings

– Monthly Summary Report of LTC Facilities Reviewed-statistics/trends

found during the LTC audits.

– FAQs

– LTC Per Diem Table

– Autoclosure


Low Risk Medium Risk

High Risk

– 90-100 percent validation

rate will be audited at a

maximum of every three

years.

– 80-89.9 percent

validation rate will be

audited at a maximum of

every two years.

– 79.9 percent or lower

validation rate will be

audited every four to

twelve months.

LTC Case Mix Audit Process

HP Enterprise Services completes a Case-Mix Audit, Level of Care Audit, and Pre-Admission Screening Resident Review (PASRR) for all IHCP facilities in the state of Indiana according to the following case-mix audit/validation rate categories:

Refer to Bulletin BT200936 for audit frequency.



– HP provides advance notification to the nursing facility.

• This notification is as many as 72 hours before the audit.

• See 405 IAC 1-15-5 for more information.

– The audit includes:

• The greater of 30 percent of the total assessments or a

minimum of 25 assessments.

• The MDS 3.0 assessments subject to audit are those most

recently transmitted to Myers and Stauffer LC.



–The HP LTC audit team conducts an entrance and exit

conference with each nursing facility.

• The nursing facility is not required to print a hard copy of

the MDS 3.0 assessment that is transmitted, which is the

basis for the MDS 3.0 case-mix audit, unless requested by

the HP auditors.

• HP audits the MDS 3.0 supporting documentation

maintained by nursing facilities for residents, regardless of

payer type.


LTC Case Mix Audit Process Requested Information

–Alphabetical resident list, which includes the following:

• Last name

• First name

• Date of birth

• Date of admission

• Medicaid number or Social Security number

–Alphabetical Level II Resident List

–Current facility e-mail address for future correspondence



–The HP audit team reviews the following two parts of each

record:

• Activities of daily living (ADL) component

• Element component

–The HP audit team considers a record to be unsupported

when there is a lack of documentation to support the RUG

as a result of the audit.



–When the HP LTC audit team is unable to support a record,

the team requests that the nursing facility find supporting

documentation.

–The nursing facility must provide documentation to support

records prior to the start of the exit conference.



–“If the percentage of assessments of all residents that are

unsupported is greater than the threshold percentage … a

corrective remedy shall apply.”

• See 405 IAC 1-14.6-4 for more information.

–When the preliminary validation rate for the initial sample is

below 80 percent, the audit expands to

include the greater of an additional 20 percent of the

assessments or a minimum of 10 additional assessments

consisting of 90 percent Medicaid payer source

assessments and 10 percent non-Medicaid payer source

assessments.



–The nursing facility must provide documentation to support

records prior to the exit conference.

–The threshold percent is 20 percent and therefore, the

required validation rate for case mix audits is 80 percent or

greater.

–Prior to the exit conference at least one HP audit team

member will observe all residents that were audited.

–The HP LTC audit team ensures relevant nursing facility

staff are aware of the exit conference.



–HP sends, via email, the final summary letter to the nursing

facility approximately 10 business days following the exit

conference.

–The letter details the Summary of Findings and the Final

validation rate.


Informal Reconsideration Process

–The request must include specific audit issues that the

nursing facility believes were misinterpreted or misapplied

during the audit.

–HP must receive the request in writing no later than 15

business days from the date of the letter.

–HP forwards final results to Myers and Stauffer LC upon

completion of the audit process.


RUG Classifications

– Extensive Services

– Rehabilitation

– Special Care

– Clinically Complex

– Impaired Cognition

– Behavior

– Reduced Physical


Activities of Daily Living (ADL) Assistance

– G0110A, 1 & 2

– G0110B, 1 & 2

– G0110I, 1 & 2

– G0110H, 1

– Included in coma string impacting Extensive Services

count in Clinically Complex and Impaired Cognition.

– Documentation of these ADLs requires 24 hours/7days

within observation period.


RUG Classification: Extensive

– K0510A, 1 or 2 – Parenteral /IV Feedings

– O0100D, 1 or 2 – Suctioning

– O0100E, 1 or 2 – Tracheostomy Care

– O0100F, 1 or 2 – Ventilator or Respirator

– O0100H, 1 or 2 – IV Medications


RUG Classification: Rehabilitation

– O0400A, 1, 2, 3, & 4

– O0400B, 1, 2, 3, & 4

– O0400C, 1, 2, 3, & 4

– Therapies: Speech – Language Pathology and Audiology

Services; Occupational Therapy and Physical Therapy.


Active Diagnosis

– Active diagnoses are diagnoses that have a

direct relationship to the resident’s current

functional, cognitive, or mood or behavior

status, medical treatments, nursing monitoring,

or risk of death during the 7-day look-back

period.

– Active diagnosis signed by the physician

within the past 60 days (plus10-day grace

period permitted by 410 IAC 16.2-3.1-22(d)(2).

Must be signed by physician in the 7 day

assessment period.

– I2900 – Diabetes

Mellitus

– I4300 – Aphasia

– I4400 – Cerebral

Palsy

– I4900 –

Hemiplegia/Hemi-

paresis

– I5100 – Quadriplegia

– I5200 – Multiple

Sclerosis

I2000 – Pneumonia

I2100 – Septicemia


RUG Classification: Special Care

– I4400 – Cerebral Palsy

– I5100 – Quadriplegia

– I5200 – Multiple Sclerosis

– J1550A – Fever; AND One of the following; J1550B – Vomiting; J1550C Dehydrated; K0300, 1 or 2 – Weight loss; K0510B, 1 or 2 – Feeding tube; I2000 – Pneumonia, included in Fever string impacting Special Care

– I4300 – Aphasia; K0510B, 1 or 2 – Feeding Tube; K0700A – Portion of total calories and K0700B – Average Fluid per day with feeding tube. If administered outside of facility, evidence of administration record must be provided within the observation period.



– K0700A – Proportion of total calories the resident received through parenteral or tube feeding. For residents receiving oral nutrition and tube feeding, documentation must demonstrate how the facility calculated the percentage of calorie intake the tube provided and include:

• Calories tube feeding provided during observation period

• Calories oral feeding provided during observation period

• Percent of total calories provided by tube feeding

• Calories by tube/total calories consumed



– M0300A – Number of Stage I pressure ulcers

– M0300B,1 – Number of Stage 2 pressure ulcers

– M0300C,1 – Number of Stage 3 pressure ulcers

– M0300D,1 – Number of Stage 4 pressure ulcers

– M0300F,1 – Number of Unstageable pressure ulcers

Note: Documentation must include staging of the pressure ulcer(s) within the observation period. Each ulcer should have an entry noting observation date, location, and measurement/description.



– M1030 – Number of venous and arterial ulcers

– M1040D – Open lesion(s) other than ulcers, rashes, cuts

– M1040E – Surgical wound(s)



– M1200A, B – Pressure reducing devices for chair, bed

Note: Facilities providing pressure-reducing mattresses for all

beds should have a documented policy noting such and be

prepared to provide evidence of the policy to the audit team.

– M1200C – Turning/repositioning program

– M1200D – Nutrition or hydration intervention to manage skin

problems

– M1200E – Pressure Ulcer care

These elements may impact the strings with staged wounds.



– M1200F – Surgical wound care impacting strings with

surgical wounds

– M1200G – Application of non-surgical dressings (with or

without topical medications) other than to feet

– M1200H – Application of ointments/medications other than

to feet

Both M1200G & H impact strings with staged wounds

and surgical wounds.



– O0100B, 1 or 2 – Radiation

– O0400D2 – Respiratory therapy

• 7 Days 15 minutes each day

• Respiratory assessment documented at least once

during observation period

• Performed by qualified individuals, evidence of training

must be provided


RUG Classification: Clinically Complex

– D0200A – I, 2 – Resident Mood Interview (PHQ-9©); minimum documentation – resident mood interview symptom frequency codes are sufficient. MDS will be considered source document.



– D0500A – J, 2 – Staff assessment of Resident Mood

(PHQ-9-OV©)

Documented examples demonstrating the presence and

frequency of the clinical mood indicators must be provided

during the observation period.



– B0100 – Comatose

– I2000 – Pneumonia

– I2100 – Septicemia

– I2900 – Diabetes Mellitus included in diabetes string,

(I2900 & N0300 & O0700)

– I4900 – Hemiplegia/Hemiparesis

– J1550C – Dehydrated

– J1550D – Internal bleeding



– K0510B, 1 or 2 – Feeding Tube; K0700A – Portion of total

calories and K0700B – Average Fluid per day with feeding tube

– M1040A – Infection of foot

– M1040B – Diabetic foot ulcer(s)

– M1040C – Other open lesion(s) on foot

– M1040F – Burn(s)

– M1200I – Application of dressings to feet (with or without

topical medications), impacting strings with skin conditions of

foot

– N0300 – Injections – impacting diabetes string



– O0100A, 1 or 2 – Chemotherapy

– O0100C, 1 or 2 – Oxygen therapy

– O0100I, 1 or 2 – Transfusions

– O0100J, 1 or 2 – Dialysis

– O0600 – Physicians’ examinations

– O0700 – Physician orders


RUG Classification: Impaired Cognition

– B0100 – Comatose

– B0700 – Makes Self Understood

– C0200 – Repetition of three words

– C0300A, B, C – Temporal orientation – year, month, week

– C0400A, B, C – Recall

– C0700 – Short-term memory OK

– C1000 – Cognitive skills for daily decision making


Additional Information for BIMS

– BIMS Codes are sufficient.

– MDS will be considered source document.

– C0200 – Repetition

of Three Words

– C0300A,B,C –

Temporal orientation

– year, month, week

– C0400A,B,C -

Recall


Behavior Problems

RUG Classification

– E0100A – Hallucinations

– E0100B – Delusions

– E0200A – Physical behavioral symptoms (coded 2 or 3)

– E0200B – Verbal behavioral symptoms (coded 2 or 3)

– E0200C – Other behavioral symptoms (coded 2 or 3)

– E0800 – Rejection of Care (coded 2 or 3)

– E0900 – Wandering (coded 2 or 3)


Nursing Restorative Programs

– H0200C – Current urinary toileting program or trial

– H0500 – Bowel toileting program

– O0500 A, B, C, D, E, F, G, H, I, J – Restorative nursing

programs

– Documentation during the observation must include the

five criteria for restorative nursing care.


Supportive Documentation Guidelines

(SDGs) MDS 3.0

Effective for assessments dated

June 1, 2012 or after


Overall Documentation Instructions

– Supportive documentation in the medical record must be

dated during the assessment reference period to support

the MDS 3.0 responses.

– Each page or individual document must contain the

resident identification information.

– Correction/Obliterations/Errors/Mistaken Entries: At a

minimum, the HP audit team must see one line through

the incorrect information, the staff’s initials, the date the

correction was made and the correct information.



– Supportive documentation entries must be dated and their authors identified by signature or initials.

– Signatures are required to authenticate all medical records. At a minimum, the signature must include the first initial, last name, and title/credential.

– Any time a facility chooses to use initials in any part of the record for authentication of an entry, there must also be corresponding full identification of the initials on the same form or on a signature legend.



– Initials may never be used where a signature is required by law (that is, on the MDS).

– When electronic signatures are used, there must be policies to identify those who are authorized to sign electronically, and safeguards must be in place to prevent unauthorized use of electronic signatures.


HP Help Desk Support

HP LTC UNIT HELP DESK Questions related to the HP LTC Audits and MDS 3.0

Supportive Documentation Guidelines.

Kimberly Honeycutt, RN, QMRP, RAC-CT

(317)488-5062

[email protected]

HP PROVIDER RELATIONS HELP DESK Questions related to the LTC provider billing and claims.

(317)488-5094

mailto:[email protected]


HP LTC AUDIT

Level of Care & Pre-Admission Screening

Resident Review (PASRR)


HP LTC Audit Forms Reviewed

– During the HP LTC Audit the following forms will be reviewed

• 450B (for all Medicaid recipients)

• Level I

• Level II (if applicable)

– These forms can be copies.

– Simultaneous to the Case Mix audit, two other reviews are occurring;

Level of Care and PASRR.

• Level of Care includes reviewing whether Medicaid recipients still require Nursing

Facility (NF) care. If continued Level of Care is a concern the team will review

documentation and discuss medical needs with pertinent NF staff prior to making a

recommendation for discharge.

• PASRR includes reviewing all charts for a Level I and if applicable a Level II. When a

Level II is reviewed assessing if the recommendations are being followed.


450B form

– All Medicaid recipients should have a 450B on their chart.

• This may be a copy.

• It should be only the most recent 450B.

− For this admission

− For your NF

− With an effective date

• Procedures should be in place to ensure that effective 450B’s are copied and placed in

the current medical record.

− Most complications seem to occur when facility systems are not in place to get a copy of this effective 450B from

the Business Office Manager to the chart.


Level I form

– A Level I form is reviewed for every current resident.

• These can be copies.

• The Level I should reflect the residents current status.

• Level I’s will assist NF’s in determining the need for Level II referral.

• NF staff may complete a new Level I to ensure the form accurately

reflects the resident.

• The HP LTC auditors may make referrals for Level II’s. Information will

be provided at exit.


HP LTC Audit Referral form


Level II form

– Only the most recent Level II should be in the current medical record.

– Information from the Level II should be integrated into the care

planning process, i.e. diagnosis and recommendations.

– All Level II’s that confirm MI or DD or MI/DD will be reviewed.

– Residents in the Case Mix audit will have Level II recommendations

reviewed for compliance.


Recommendations vs requirements

Level II Recommendations

– Who can refuse recommendations?

• Resident

• Legal Guardian

• Health Care Representative

• Durable Power of Attorney

– Documentation must detail refusal.

– Clinicians can document resident’s discharge from mental health care.

• If care is no longer needed NF should assess accuracy of Level I and possibly request

new Level II for condition change.


Only most recent on

chart

Exception

Only one?

Level II’s

– DD Level II says NO

• This record should always remain on the chart.

– If Level II for MI is completed most recent

should be on the chart

– Both should be in the chart.


Reference Material

– PASRR Manual

• Contact Area Agency on Aging (AAA) for copy (currently using version January 2000)

• Manual being revised.

– Reviews how and when to complete a Level I

– Defines Mental Illness and Developmental Disability

– Discusses Dementia and Dementia exclusions

– Includes PAS & PASRR scenarios


450B Level I

Level II

Reminder of the 3 forms reviewed in the Case Mix audit

– May be a copy

– For all Medicaid

residents

– With the most recent

‘effective Medicaid

reimbursement date’

completed by state

– May be a copy

– Should reflect the

resident’s current status

– May indicate need for

Level II

– May be a copy

– MI or DD or MI/DD

– Need only most recent

on the medical record.

– Should be incorporated

into care planning

– Documentation must

reflect the current status

of recommendations


Q & A

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